Finally, patients with DEB often are comfortable allowing large wounds to heal by secondary intention and are familiar with the required wound care.Most importantly, the surgeon should do no harm. The primary iatrogenic risk for these patients is new wounds from inadvertent shearing. We have several strategies to reduce this risk. First, when possible, allow time for the patient to remove and reapply his or her own dressings. These patients are experts in wound care and have found efficient dressing regimes through trial and error. Second, the surgeon should suture on bolsters, use surgical glue instead of adhesive strips and always apply liberal amounts of lubricating ointment on everything that touches the patient. Third, these patients often have esophageal strictures and limited mouth opening, which increase the difficulty of general anesthesia. Therefore, if possible, we perform the excision and dermal substitute placement using intravenous sedation with the area anesthetized with lidocaine with epinephrine. Finally, the physician should not underestimate the psychologic implications of harvesting skin. These patients spend their whole lives protecting their skin and removing the little remaining normal skin can be deeply upsetting (as well as technically challenging).